Add a Provider

Provider Added For:


Provider details


Professional Credentials


Work History

(Please provide work history for the past 6 years, any gaps exceeding 6 months provide an explanation. If you require additional space, please fill in the first two and attach additional documentation below by clicking on the "UPLOAD" button.)

Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB

Work History

(Please provide work history for the past 6 years, any gaps exceeding 6 months provide an explanation. If you require additional space, please fill in the first two and attach additional documentation below by clicking on the "UPLOAD" button.)

Please upload your supporting documents including: • license • insurance • diploma (if applicable) • W-9

Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB
Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB
Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB
Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB

Education


Compliance Checklist


Provider Newsletter

I attest this information is true and accurate to the best of my knowledge and that Hearing Care Solutions, Inc. may use this information for any credentialing needs.